How to overcome a resistant cervix for hysteroscopy and endometrial biopsy

If the sampling device does not pass easily through the cervix, use a tenaculum and a lacrimal duct probe or small Hagar dilators to dilate the cervix.²⁸

Pain may again be an issue

Almost 50% of women experience moderate or severe pain during endometrial biopsy.³² Many clinicians recommend giving an oral NSAID 60 minutes before the procedure to decrease discomfort. One study found that the use of naproxen sodium before Vabra curettage reduced the severity of pain at 30 and 60 minutes after the procedure, but did not alleviate discomfort arising during the biopsy itself.¹⁴ Another study suggested the combination of naproxen sodium and intrauterine lidocaine (5 mL of 2% lidocaine) to reduce discomfort associated with the procedure.³⁰

Use of anesthesia is controversial

A study by Lau and colleagues¹⁷ found paracervical lignocaine to be ineffective at reducing pain during hysteroscopy and endometrial biopsy, but the drug did increase the risk of bradycardia and hypotension. Another study demonstrated a decrease in procedure-related discomfort in postmenopausal women who were given 2 mL of 2% intrauterine mepivacaine.²⁰ These findings are similar to those of Zupi and associates.¹⁹

Consider the tool

Discomfort may be related to the size of the biopsy catheter. Pain scores appear to be significantly lower with the Pipelle biopsy catheter than with the larger Novak biopsy curette.³²

Vasovagal reaction usually resolves after the procedure

As with hysteroscopy, women may occasionally experience a vasovagal reaction during endometrial biopsy. This complication usually resolves quickly once the procedure is completed.²⁹ Some clinicians suggest that the patient be allowed to eat and drink before the procedure and be given an analgesic before it begins.²⁸

Cervical priming is not a proven strategy

Misoprostol has been considered as a preprocedure adjunct to endometrial biopsy. Only one small randomized, controlled trial involving 42 women has evaluated the drug for this indication. It found no benefit when 400 μg of misoprostol was given orally 3 hours before the procedure, as well as cramping and increased pain during the biopsy.³³ This study had several shortcomings, including its small sample size and the inclusion of both pre- and postmenopausal women. Further research is needed—separately in premenopausal and postmenopausal women and with adequately large samples—to assess the use of misoprostol.

The author reports no financial relationships relevant to this article.